Provider Demographics
NPI:1477838852
Name:CAROL A. MCKINNON, LCSW
Entity Type:Organization
Organization Name:CAROL A. MCKINNON, LCSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MCKINNON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-292-5439
Mailing Address - Street 1:8835 SW CANYON LN
Mailing Address - Street 2:SUITE 240
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-3443
Mailing Address - Country:US
Mailing Address - Phone:503-292-5439
Mailing Address - Fax:181-379-2339
Practice Address - Street 1:8835 SW CANYON LN
Practice Address - Street 2:SUITE 240
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-3443
Practice Address - Country:US
Practice Address - Phone:503-292-5439
Practice Address - Fax:181-379-2339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROREGON 0326101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000BHTFNMedicare PIN
ORA42872Medicare UPIN